| NPI | 1023779857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA100222) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12537) |
| Enumeration Date | 2022-01-04 |
| Last Update Date | 2024-04-03 |